also more commonly known as a pressure sore or a "bed sore".
It can range from a very mild pink coloration of the skin, which disappears in a few hours after pressure is relieved on the area, to a very deep wound extending to and sometimes through a bone into internal organs.
they are classified in stages according to the severity of the wound.
Causes
when pressure is exerted on a bony part of the body for long periods of time
when friction is applied (i.e. against a bed sheet or cast) or when person is exposed to cold for a long period of time.(not common)
Areas of the body that can form bed sores:
spine
coccyx or tailbone
hips
heels
elbows
shoulder blades
anywhere where blood flow may be decreased because of pressure
Mechanism of formation
The weight of the person's body presses on the bone, the bone presses on the tissue and skin that cover it, and the tissue is trapped between the bone and bed or wheelchair surface. The tissue begins to decay from lack of blood circulation.
Stages of Wounds
Stage I
This stage is characterized by surface reddening of the skin. The skin is unbroken and the wound is superficial. This would be a light sunburn or a first degree burn as well as a beginning Decubitus ulcer. The burn heals spontaneously or the Decubitus ulcer quickly fades when pressure is relieved on the area.
The key factors to consider in a Stage I wound is what was the cause of the wound and how to alleviate pressure on the area to prevent it from worsening. Preventive care is taken during this stage so ulcer doesn't worsen.
Treatment consists of turning or alleviating pressure in some form or avoiding more exposure to the cause of the injury as well as covering, protecting, and cushioning the area. Soft protective pads and cushions are often used for this purpose. An increase in vitamin C, proteins, and fluids is recommended. Increased nutrition is part of prevention.
Stage II
This stage is characterized by a blister either broken or unbroken. A partial layer of the skin is now injured. Involvement is no longer superficial.
The goal of care is to cover, protect, and clean the area. Coverings designed to insulate and absorb as well as protect are used.
Skin lotions or emollients are used to hydrate surrounding tissues and prevent the wound form worsening. Additional padding and protective substances to decrease the pressure on the area are important. Close attention to prevention, protection, nutrition, and hydration is important also. With quick attention, a stage II wound can heal very rapidly.
A wound can appear to be a Stage I wound upon initial evaluation, and actually be reevaluated as a Stage II wound during the course of care. Quick attention to a Stage I Decubitus ulcer or pressure wound will prevent the development of a Stage III Decubitus ulcer or pressure wound. Generally Decubitus ulcers developing beyond Stage II is from lack of intervention when first noted.
Stage III
The wound extends through all of the layers of the skin. It is a primary site for a serious infection to occur.
The goals and treatments of alleviating pressure and covering and protecting the wound still apply as well as an increased emphasis on nutrition and hydration.
Medical care is necessary to promote healing and to treat and prevent infection. This type of wound will progress very rapidly if left unattended. Infection is of major concern.
Stage IV
A Stage IV wound extends through the skin and involves underlying muscle, tendons and bone. The diameter of the wound is not as important as the depth. This is very serious and can produce a life threatening infection, especially if not aggressively treated. All of the goals of protecting, cleaning and alleviation of pressure on the area still apply. Nutrition and hydration is now critical. Without adequate nutrition, this wound will not heal.
Anyone with a Stage IV wound requires medical care by someone skilled in wound care. Surgical removal of the necrotic or decayed tissue is often used on wounds of larger diameter. A skilled wound care physician, physical therapist or nurse can sometimes successfully treat a smaller diameter wound without the necessity of surgery. Surgery is the usual course of treatment. Amputation may be necessary is some situations.
Stage V(not usually used)
This is an older classification and not now used in all areas. A stage 5 wound is a wound that is extremely deep, having gone through the muscle layers and now involves underlying organs and bone. It is difficult to heal. Surgical removal of the necrotic or decayed tissue is the usual treatment. Amputation may be necessary is some situations.
Prevention
Provide good skin care. Use mild soap and gentle strokes with a soft washcloth when giving a bath to a resident or patient. Rinse the skin well and then pat it dry with a soft towel. Use a bland lotion to lubricate dry skin. Lotion helps to keep the skin healthy and soft. Do NOT use alcohol or alcohol base lotions on skin. Alcohol dries the skin. Look at areas where skin touches skin, such as under the breasts. If these areas are moist, place a light dusting of corn starch to help keep this area dry.
Keep the skin clean and dry. Immediately remove all wet or dirty linens, briefs and clothing. Do not let the patient remain wet or dirty with urine, feces or other fluids, including water or tea. Wash, rinse and dry all wet and dirty skin as your read above.
Turn and position patients at least every 2 hours. Patients and residents who stay in bed, the chair or wheelchair must be moved and re-positioned at least every 2 hours. Many patients have to be turned and positioned even more often if they are at risk for pressure ulcers. Make the time to move your patients. It takes much more time to treat a pressure ulcer than it takes to turn a patient.
Observe and report the condition of the skin. Look at and observe the patient's skin for signs of whiteness (blanching), redness, heat, tearing or breaks.
Encourage mobility. Encourage your patients to ambulate and move if it is okay with their doctor. Walking and moving about increases blood flow and it keeps patients out of bed and the chair when they are able to do so.
Provide for toileting needs. Anticipate the patient's need to use the bathroom. Patients that are wet with urine or soiled with feces are at risk of getting a pressure ulcer.
Encourage and provide nutrition and fluids. Encourage the resident or patient to eat good foods and lots of fluids. Every time you are with a patient, ask them if they would like a drink of water or juice. Make meal times happy and pleasant. Encourage the patient to eat their whole meal. If they are not eating, offer them another choice of food. Report and record all food and fluid intake.
Use pressure reducing cushions, mattresses, beds, booties, elbow pads, etc. These items lower pressure when patients stay in the bed or chair for long periods of time.
Document and report all your patient observations and care. Nursing assistants must report if the patient is not eating or drinking, if they are not getting out of bed and if you see a red area on the patient's skin.
Do NOT!!
Do NOT elevate the head of the bed more than 30 degrees, unless ordered. If the bed is higher than this, it will cause friction, shearing and the need to pull the patient up in the bed more often than necessary.
Do NOT use any donut type devices. These devices create uneven pressure, a force that leads to pressure ulcers.
Do NOT allow a patient to remain on a bedpan for a long period of time. Remaining on a bedpan also creates pressure, a force that leads to pressure ulcers.
Causes
Areas of the body that can form bed sores:
Mechanism of formation
Stages of Wounds
Stage I
This stage is characterized by surface reddening of the skin. The skin is unbroken and the wound is superficial. This would be a light sunburn or a first degree burn as well as a beginning Decubitus ulcer. The burn heals spontaneously or the Decubitus ulcer quickly fades when pressure is relieved on the area.The key factors to consider in a Stage I wound is what was the cause of the wound and how to alleviate pressure on the area to prevent it from worsening. Preventive care is taken during this stage so ulcer doesn't worsen.
Treatment consists of turning or alleviating pressure in some form or avoiding more exposure to the cause of the injury as well as covering, protecting, and cushioning the area. Soft protective pads and cushions are often used for this purpose. An increase in vitamin C, proteins, and fluids is recommended. Increased nutrition is part of prevention.
Stage II
This stage is characterized by a blister either broken or unbroken. A partial layer of the skin is now injured. Involvement is no longer superficial.The goal of care is to cover, protect, and clean the area. Coverings designed to insulate and absorb as well as protect are used.
Skin lotions or emollients are used to hydrate surrounding tissues and prevent the wound form worsening. Additional padding and protective substances to decrease the pressure on the area are important. Close attention to prevention, protection, nutrition, and hydration is important also. With quick attention, a stage II wound can heal very rapidly.
A wound can appear to be a Stage I wound upon initial evaluation, and actually be reevaluated as a Stage II wound during the course of care. Quick attention to a Stage I Decubitus ulcer or pressure wound will prevent the development of a Stage III Decubitus ulcer or pressure wound. Generally Decubitus ulcers developing beyond Stage II is from lack of intervention when first noted.
Stage III
The wound extends through all of the layers of the skin. It is a primary site for a serious infection to occur.The goals and treatments of alleviating pressure and covering and protecting the wound still apply as well as an increased emphasis on nutrition and hydration.
Medical care is necessary to promote healing and to treat and prevent infection. This type of wound will progress very rapidly if left unattended. Infection is of major concern.
Stage IV
A Stage IV wound extends through the skin and involves underlying muscle, tendons and bone. The diameter of the wound is not as important as the depth. This is very serious and can produce a life threatening infection, especially if not aggressively treated. All of the goals of protecting, cleaning and alleviation of pressure on the area still apply. Nutrition and hydration is now critical. Without adequate nutrition, this wound will not heal.Anyone with a Stage IV wound requires medical care by someone skilled in wound care. Surgical removal of the necrotic or decayed tissue is often used on wounds of larger diameter. A skilled wound care physician, physical therapist or nurse can sometimes successfully treat a smaller diameter wound without the necessity of surgery. Surgery is the usual course of treatment. Amputation may be necessary is some situations.
Stage V(not usually used)
This is an older classification and not now used in all areas. A stage 5 wound is a wound that is extremely deep, having gone through the muscle layers and now involves underlying organs and bone. It is difficult to heal. Surgical removal of the necrotic or decayed tissue is the usual treatment. Amputation may be necessary is some situations.Prevention
- Provide good skin care. Use mild soap and gentle strokes with a soft washcloth when giving a bath to a resident or patient. Rinse the skin well and then pat it dry with a soft towel. Use a bland lotion to lubricate dry skin. Lotion helps to keep the skin healthy and soft. Do NOT use alcohol or alcohol base lotions on skin. Alcohol dries the skin. Look at areas where skin touches skin, such as under the breasts. If these areas are moist, place a light dusting of corn starch to help keep this area dry.
- Keep the skin clean and dry. Immediately remove all wet or dirty linens, briefs and clothing. Do not let the patient remain wet or dirty with urine, feces or other fluids, including water or tea. Wash, rinse and dry all wet and dirty skin as your read above.
- Turn and position patients at least every 2 hours. Patients and residents who stay in bed, the chair or wheelchair must be moved and re-positioned at least every 2 hours. Many patients have to be turned and positioned even more often if they are at risk for pressure ulcers. Make the time to move your patients. It takes much more time to treat a pressure ulcer than it takes to turn a patient.
- Observe and report the condition of the skin. Look at and observe the patient's skin for signs of whiteness (blanching), redness, heat, tearing or breaks.
- Encourage mobility. Encourage your patients to ambulate and move if it is okay with their doctor. Walking and moving about increases blood flow and it keeps patients out of bed and the chair when they are able to do so.
- Provide for toileting needs. Anticipate the patient's need to use the bathroom. Patients that are wet with urine or soiled with feces are at risk of getting a pressure ulcer.
- Encourage and provide nutrition and fluids. Encourage the resident or patient to eat good foods and lots of fluids. Every time you are with a patient, ask them if they would like a drink of water or juice. Make meal times happy and pleasant. Encourage the patient to eat their whole meal. If they are not eating, offer them another choice of food. Report and record all food and fluid intake.
- Use pressure reducing cushions, mattresses, beds, booties, elbow pads, etc. These items lower pressure when patients stay in the bed or chair for long periods of time.
- Document and report all your patient observations and care. Nursing assistants must report if the patient is not eating or drinking, if they are not getting out of bed and if you see a red area on the patient's skin.
Do NOT!!